Chemotherapy Drugs Review

Ana Corona, MSN, FNP-C Nursing Instructor December 2008

MedSurg. Nursing: Essential Oncology Facts Oncology Nursing Society 2005

Lab Values

Patients with cancer require regular monitoring of lab values by nurses who will anticipate their health care needs. Nursing interventions can include prophylactic measures if abnormal lab values are noted and addressed quickly.

Leukopenia

Chemotherapy and radiation therapy can decrease a patient's white blood cell (WBC) count and lead to leukopenia . Because neutrophils act as phagocytes, a significant decrease in the neutrophil count places a patient with cancer at high risk for infection.

Neutropenia

A measure used to assess a patient's risk for infection is the absolute neutrophil count (ANC). ANC less than 500 places the patient at severe risk for infection, and a count less than 100 constitutes extreme risk. The patient may receive medications on a daily basis to stimulate WBC production. The nurse should know the ANC prior to medication administration and take appropriate measures to prevent infection

Anemia

Anemia occurs when the patient's red blood cells (RBC) are lost or the production rate is decreased; low hemoglobin and hematocrit result. Any abnormal values should be discussed with the primary care provider because the patient with cancer may require blood transfusions before reaching critically low levels. Critical values for hemoglobin and hematocrit are less than 5.0 g/dl.

Thrombocytopenia

Thrombocytopenia occurs when platelet counts fall below 100,000. Spontaneous bleeding can occur when platelet levels fall below 20,000. To avoid an emergent situation, the nurse should report platelet count at 40,000. The patient with elevated platelets can also develop bleeding if the platelet function is abnormal.

Hematopoietic Growth Factors or Colony-stimulating factors

Medications that help improve these hematologic conditions are hematopoietic growth factors or colony-stimulating factors. These agents stimulate red and/or white blood cell production and maturation. The nurse should be aware of administration techniques, expected therapeutic outcomes, and potential adverse effects.

Colony Stimulating Factors

Filigastrim (Neupogen) and sargramostim (Leukine) are used to enhance the WBC count. Pegfiligastrim (Neulasta) for patients with a decreased WBC. These medications may be needed if the patient is receiving antineoplastic agents that suppress the bone marrow. Epoetin alfa recombinant (Procrit) is administered to maintain or increase the patient's RBC level. Positive results with this medication can decrease the need for blood transfusions.

Colony Stimulating Factors

Oprelvekin (Neumega), also known as interleukin 11, is a growth factor that is used to prevent thrombocytopenia following chemotherapy infusion. This medication allows hematopoietic stem cells and the progenitor cells to proliferate, increasing platelet production. As the plasma volume increases, the nurse may see decreased hemoglobin, decreased serum albumin, and decreased gamma globulins. The nurse must review lab values and administration routes associated with the use of colony-stimulating factors prior to their administration.

Electrolyte Imbalance

Electrolytes, essential for normal physiologic function of nerves and muscles, are monitored closely in the patient with cancer. Elevated or decreased electrolyte levels can have life-threatening effects. The nurse must anticipate problems such as cardiac dysrhythmias or uncontrolled bleeding and intervene quickly. Intravenous fluids, oral electrolyte supplements, and/or total parenteral nutrition (TPN) can influence electrolyte balances. The nurse must be able to report current lab values and all sources of ingested or parenteral electrolytes to oncology specialists.

Neutropenia Precautions

Neutropenia could be related to the cancer pathology or the result of receiving chemotherapeutic agents. Individuals with an absolute neutrophil count of less than 1,000 cells are considered neutropenic and are at moderate risk for infection. ANC less than 500 creates a severe risk for the patient, and ANC less than 100 places the patient in an extreme risk category.

Nadir

The term nadir represents that period of time when blood levels are at their lowest point. The nadir period varies for each antineoplastic agent. Most nadir periods occur approximately 10 to 14 days after the beginning of chemotherapy treatment or several weeks following radiation therapy, depending on the treatment agent and life span of the particular blood cells

Reversed Isolation Precautions

An immunocompromised state makes it difficult for the patient with cancer to combat even minor colds; sepsis can result. When assigned to care for a patient who is neutropenic, the nurse must review guidelines regarding care of an immunocompromised patient.

Common Adverse Effects of Chemotherapy and Radiation

Fatigue Nausea Pain Vomiting Oral stomatitis Bone/Joint Pain Anorexia Constipation Diarrhea Impaired skin integrity Alopecia

All patients do not experience these adverse effects; however, the nurse should be aware of assessment criteria and early intervention strategies

Fatigue: Nursing Intervention

Occurs greater than 70% It can occur when the patient reaches the nadir period. Clustering patient care activities can reduce fatigue and provide uninterrupted rest periods. A sign on the patient's room door can prompt visitors to check with the nurse before entering.

Nausea and Vomiting: Nursing Intervention

Nausea and vomiting occur frequently with the use of chemotherapeutic agents. Some chemotherapy drug regimens include antiemetics prior to administration to promote patient tolerance of the treatment. Specific food choices such as gelatin, popsicles, and soft bland food may minimize queasiness The patient should be encouraged to experiment with his or her diet to increase calories. The patient must consume an adequate number of calories to maintain nutrition balance and enhance quality of life. A dietary consult may be helpful in identifying the patient's caloric needs and identifying which foods would be best.

Oral Stomatitis: Nursing Intervention

Rapidly dividing cells in the mouth are affected by chemotherapy and radiation treatments, leading to painful mouth sores and chapped lips. Candida albicans (yeast) may occur on the tongue and oral mucosa. Often, excess oral secretions make it difficult for the patient to speak clearly or to eat a substantial amount of food. The patient may find relief from sucking on ice chips or popsicles. Several combinations of mouth rinses are available, depending on the patient's need - excess secretions may require diphenhydramine (Benadry) in a mouth rinse, for increased pain may need lidocaine or water and baking soda rinses. Frequent oral care is vital to preserve mucosal integrity. Individual needs and the extent of the stomatitis should be discussed with the primary care provider to determine the best intervention.

Bone/Joint Pain: Nursing Interventions

Bone and joint pain increases as cancer advances and as an adverse effect of colonystimulating factors. Analgesics and anti-inflammatory medications, as well as alternative pain relief measures, can be used. Alternative pain relief measures can include guided imagery, music therapy, relaxation exercises, and massage, if appropriate.

Constipation and Diarrhea: Nursing Interventions

The disease process, lack of activity, and frequent use of opioids may result in constipation. High fiber food choices, adequate fluid intake, and stool softeners are used to promote regular elimination and help prevent bloating. Diarrhea can result from frequent use of antibiotics and antiemetics. Dehydration and the loss of electrolytes, minerals, and nutrients can result. Stool specimens may he collected to determine if an infection has occurred. If no infection is detected, antidiarrheal medications may be ordered. It is important to replace lost fluids, maintain electrolyte levels, and prevent sepsis. In either constipation or diarrhea, the nurse should anticipate the patient's needs and initiate preventive measures.

Delirium: Nursing Intervention

Agitated behavior requiring sedation, also described as delirium, terminal restlessness, mental anguish and agitation, are common problems in cancer patients. Factors such as cachexia, hypoalbuminemia, advanced age, and prior dementia can contribute to this condition. Identification and treatment of delirium may involve such interventions as discontinuation or dose reduction of psychoactive medications, adjustments in fluid administration, or treatment of infections, dehydration, or electrolyte imbalances. Ongoing monitoring and reassessment are critical especially when sedatives, opioids, or other psychoactive medications are required to control patient's symptoms. Changes in the patient's health and mental status, in laboratory values, and symptoms that suggest drug toxicity should be reported promptly to the oncology specialist. A psychosocial intervention for family caregivers of patients with advanced cancer may be beneficial.

Skin Integrity: Nursing Intervention

Maintaining skin integrity is a priority during the treatment and healing process of cancer. Irradiated tissue, at risk for skin breakdown and delayed wound healing, should be assessed at least every shift. Chemotherapy and radiation injure the rapidly dividing cells of the skin. A patient with cancer may remain in bed for long periods of time due to fatigue and pain. The underlying effects to the skin may not be visible immediately, and recovery will depend on the patient's response to treatment Adequate nutrition is also an important component in maintaining skin integrity. Cancer-associated cachexia, related to inadequate caloric needs and decreased protein intake, can delay wound healing A skin assessment instrument, such as the Braden Scale, should be used to evaluate the patient each shift and determine specific interventions.

Anorexia: Nursing Intervention

Chemotherapy and radiation treatments affect rapidly dividing cells and can alter taste sensation. Mouth rinses with baking soda and water can be used to soothe the mucosa prior to meals. Megestrol acetate (Megace) has been used for appetite enhancement in the patient with advanced cancer. Liquid nutritional supplements, such as health shakes, can also be offered. The use of TPN may be necessary if other means for nutritional support are exhausted.

Chemotherapy Precautions

The nurse needs to be familiar with chemotherapy precautions, which are followed for a period of 48 hours after the patient's last dose of an antineoplastic agent. Antineoplastic agents are excreted from the body through fluids such as sweat, vomitus, stool, and urine. The nurse should use personal protective equipment (PPE) for each patient contact. PPE includes masks with face shields or goggles, chemotherapy gloves, and a fluid-resistant gown. Handwashing before and after working with the patient is essential. The nurse should cover the commode or toilet with a disposable drape to prevent fluids from splashing while flushing twice. Specified receptacles for linen and trash disposal must be used. Family members must be instructed on and follow the necessary precautions. The facility should have a policy that stipulates precautions and supplies used to protect the staff, patient, and visitors.

Q1

Patient AB is undergoing procarbazine, lomustine, and vincristine chemotherapy for a brain tumor. Teaching points regarding procarbazine include
A. B.

C.

D.

Alcohol may be ingested in moderation. Take the procarbazine at the same time as the lomustine to enhance efficacy. Avoid foods and beverages with high tyramine content during procarbazine therapy. Take the medication at bedtime because drowsiness is a common adverse effect, and do not operate machinery or motor vehicles while taking procarbazine.

A1

The correct answer is c, avoid foods and beverages with high tyramine content during procarbazine therapy. Procarbazine is a weak monoamine oxidase inhibitor and may interact with substances that have a high tyramine content. Examples include aged cheeses, some wines, yogurt, and bananas (not a complete list). Choice a, alcohol may be ingested in moderation, is incorrect; alcohol should be avoided because of the potential for a disulfiram-like reaction to occur with procarbazine. Choice b, take the procarbazine at the same time as the lomustine to enhance efficacy, is incorrect. Procarbazine, lomustine, and vincristine regimen includes lomustine only on day one and procarbazine later in the cycle, so these drugs are not taken simultaneously. Choice d, take the medication at bedtime because drowsiness is a common adverse effect, and do not operate machinery or motor vehicles while taking procarbazine, is incorrect. Procarbazine alone generally does not cause drowsiness. However, research has suggested that procarbazine in combination with other central nervous system depressants may enhance this effect. Patients with brain tumors often are not able to drive safely and should be cautioned in this regard, but procarbazine use alone is not necessarily a limiting factor.

Q2

Several months later, AB returns to the clinic. He will leave today with a prescription for five daily doses of temozolomide to treat his progressive tumor. AB has experienced some confusion recently and comes to you with his wife for education regarding his new treatment regimen prior to leaving the clinic. You tell Mr. and Mrs. AB
A. B.

C.

D.

To take the medication with breakfast to minimize the risk of nausea. To plan ahead for a refill so temozolomide will be available on day six and therapy will not be interrupted. To contact the physician to obtain antinausea medication only if AB experiences nausea or emesis during therapy. To expect the medication to be dispensed in five daily dose packs by the pharmacy and to question the pharmacist if the temozolomide is not dispensed in this fashion.

A2

The correct answer is d, to expect the medication to be dispensed in five daily dose packs by the pharmacy and to question the pharmacist if the temozolomide is not dispensed in this fashion. Pharmacists are instructed to dispense temozolomide in daily dose packs to facilitate patient understanding and compliance. The manufacturer recommends administration on an empty stomach to minimize the risk of nausea and emesis, making choice a, to take the medication with breakfast to minimize the risk of nausea, incorrect. Even so, the incidence of nausea and emesis is high enough to justify prophylactic antiemetics with the first dose; therefore, choice c, to contact the physician to obtain antinausea medication only if AB experiences nausea or emesis during therapy, is incorrect. Choice b, To plan ahead for a refill so temozolomide will be available on day six and therapy will not be interrupted, is incorrect because the approved temozolomide regimen consists of a five-day cycle every 28 days. Fatal medication errors with temozolomide have occurred, apparently related to patient misunderstanding of the five-day cycle. Exceptions to the five-day cycle may occur in the context of a clinical trial.

Q3

Patient CD takes oral methotrexate as one component of a treatment protocol for lymphoma. Because methotrexate is subject to numerous drug interactions, you decide to review her medication profile. Which of these medications can be administered safely concurrently with methotrexate?
A. B.

C.
D.

Aspirin Cotrimoxazole Prochlorperazine Leucovorin

A3

The correct answer is c, prochlorperazine. Fortunately, antiemetics in general are safe to administer with methotrexate. This includes phenothiazines such as prochlorperazine, dexamethasone or other steroids, and serotonin antagonists such as ondansetron, dolasetron, and granisetron. Choices a, aspirin, and b, cotrimoxazole, are incorrect because salicylates and sulfa drugs can exacerbate the toxicity of methotrexate via two mechanisms: displacement of methotrexate from protein-binding sites and competition with renal tubular secretion sites, thus reducing renal clearance. Choice d, leucovorin, is incorrect. Leucovorin often is indicated for methotrexate rescue, but these two agents should not be given concurrently. Rather, leucovorin should be given after methotrexate. Check specific treatment protocols for details of timing and administration.

Q4

Patient EF takes capecitabine as a single agent to treat her refractory breast cancer. You are working with the physician to assess EFs tolerance of this regimen. She is responding to therapy and is feeling well, except for a slight tingling in the palms of her hands. Your assessment and advice include
A.
B.

C.

D.

Apply cold packs to her hands, and ask the physician to reduce her dose. Ask the physician to consider stopping capecitabine and changing EF to another regimen. Encourage EF to continue therapy, monitor the tingling, and report any worsening of symptoms. Thoroughly review EFs medication list because capecitabine is not associated with this symptom.

A4

The correct answer is c, encourage EF to continue therapy, monitor the tingling, and report any worsening of symptoms. According to the product information, tingling without other symptoms is a grade 1 hand-foot syndrome. Although a dose reduction is not recommended for this level of toxicity, EF should be monitored for any worsening of symptoms because highergrade hand-foot syndrome will necessitate disruption of therapy and/or dose reduction. Choice a, apply cold packs to her hands, and ask the physician to reduce her dose, is incorrect. Topical emollient or oral pyridoxine may help relieve the symptoms of hand-foot syndrome, but no evidence supports application of cold packs. Choice b, ask the physician to consider stopping capecitabine and changing EF to another regimen, is also incorrect. As previously stated, the symptoms described represent a grade 1 toxicity that does not justify a therapy change in a patient who is responding to treatment. Choice d, thoroughly review EFs medication list because capecitabine is not associated with this symptom, is incorrect. Hand-foot syndrome often presents with tingling in the palms of hand or soles of feet and is a common adverse effect of capecitabine.

Q5

This drug is an orally administered epidermal growth factor receptor (EGFR) inhibitor.
A.

B.
C. D.

Imatinib G efitinib Cetuximab Bortezomib

A5

The correct answer is b, gefitinib. Choice a, imatinib, is a signal transduction inhibitor that does not act by EGFR inhibition and therefore is not correct. Choice c, cetuximab, is incorrect because this is an EGFR inhibitor but is not given orally. Choice d, bortezomib, is an injected proteasome inhibitor and thus is incorrect.

Q6

Patient GH is undergoing induction chemotherapy for acute promyelocytic leukemia (APL). The induction regimen includes tretinoin (all-trans retinoic acid [ATRA], Vesanoid, Roche Laboratories, Inc., Nutley, NJ). You will closely monitor GH for signs and symptoms of retinoic acid-APL syndrome or dedifferentiation syndrome, including
A. B. C. D.

Weight loss. Hyperuricemia. Fever and dyspnea. Hives and urticaria.

A6

The correct answer is c, fever and dyspnea. Fever and dyspnea are common signs of this syndrome. As many as 25% of patients undergoing tretinoin therapy may experience dedifferentiation syndrome. Risk may be increased by leukocytosis at presentation or by rapidly evolving leukocytosis as treatment of the APL commences. Concomitant initial chemotherapy may reduce the risk of dedifferentiation syndrome. This syndrome is characterized by some or all of the following: fever, dyspnea, weight gain, pulmonary infiltrates, and pleural or pericardial effusions. Choice a, weight loss, is not correct because weight gain, not loss, sometimes is associated with this syndrome. Choice b, hyperuricemia, is incorrect because hyperuricemia may occur during induction therapy for acute leukemias, but this abnormality is related to tumor lysis syndrome, not ATRA syndrome. Choice d, hives and urticaria, is incorrect; the syndrome does not include a rash as described.

Q7

Patient IJ is being initiated on thalidomide 100 mg a day by mouth. What common side effect should you discuss with IJ?
A.

B.
C. D.

Sedation Diarrhea Insomnia Hypertension

A7

The correct answer is a, sedation. Thalidomide initially was developed as a sedative, and sedation is a common adverse effect. Choice c, insomnia, therefore is not correct. Choice b, diarrhea, is incorrect; thalidomide is much more likely to cause constipation than diarrhea. Choice d, hypertension, is not the best choice; thalidomide is not commonly associated with hypertension but can cause orthostatic hypotension. Other thalidomide side effects include human teratogenesis, dizziness, peripheral neuropathy, and headache.

Q8

Your patient, KL, is beginning treatment with imatinib for chronic myelogenous leukemia. To minimize gastrointestinal distress, you instruct KL to
A. B. C.

D.

Take imatinib with food and a full glass of water. Take imatinib with a full glass of grapefruit juice. Take imatinib on an empty stomach with a sip of water. Take imatinib on an empty stomach with a full glass of water.

A8

Choice a, take imatinib with food and a full glass of water, is the correct answer. Imatinib is well absorbed after oral administration but is associated with some gastrointestinal (GI) irritation. The patient should be instructed to take imatinib with food and a full glass of water to help minimize GI distress. Choice b, take imatinib with a full glass of grapefruit juice, is incorrect. Metabolism of imatinib is largely via the cytochrome P450 enzyme system. Concurrent intake of grapefruit juice may inhibit cytochrome P450 and increase the serum level of imatinib. Choices c, take imatinib on an empty stomach with a sip of water, and d, take imatinib on an empty stomach with a full glass of water, are incorrect. Taking imatinib on an empty stomach may increase the risk of GI irritation.

Q9

While consulting with your patient, MN, who is commencing bexarotene treatment for cutaneous T cell lymphoma, nursing considerations should include
A. B. C.

D.

Educating the patient to increase vitamin A intake. Monitoring serum triglyceride and cholesterol levels. Instructing the patient to get plenty of sun exposure to avoid vitamin D deficiency. Suggesting the administration of lipid-lowering agents such as a statin and gemfibrozil.

A9

The correct answer is choice b, monitoring serum triglyceride and cholesterol levels. Elevated triglyceride and cholesterol levels are fairly common and may be dose limiting. Because bexarotene is a retinoid and chemically related to vitamin A, patients taking the drug should be educated to limit vitamin A intake to avoid possible additive toxicity. Therefore, choice a, educating the patient to increase vitamin A intake, is incorrect. Choice c, instructing the patient to get plenty of sun exposure to avoid vitamin D deficiency, is incorrect. Photosensitivity is possible with vitamin A derivatives, so patients should be instructed to use protection from the sun; for example, apply a sunscreen when going outdoors and stay in the shade as much as possible. Choice d, suggesting the administration of lipidlowering agents such as a statin and gemfibrozil, is incorrect. Preemptive prescribing of lipid-lowering agents is not recommended. Lipid profile should be monitored, however, and therapy initiated as indicated. Drug interactions must be taken into consideration when selecting therapy. Gemfibrozil may elevate bexarotene levels via cytochrome P450 inhibition.

Q10

General teaching points for patients who will selfmedicate with an oral cytotoxic agent in the home include
A.

B.

C.

D.

Any missed dose always and immediately should be replaced by taking two doses. Any patient with a dry mouth should crush all medications and mix with water or other liquid to facilitate swallowing. Child-resistant containers are never recommended because these may interfere with many patients ability to comply with therapy. Oral cytotoxics should be stored in a safe location out of reach of children and pets, using child-resistant packaging whenever possible.

A10

The correct answer is d, oral cytotoxics should be stored in a safe location out of reach of children and pets, using child-resistant packaging whenever possible. Children and pets must be protected from all inadvertent medication exposure, but oral cytotoxics may be particularly dangerous. Patients who have difficulty opening child-resistant containers must be provided with prescription containers that are easy to manage, but use of such packaging should be an exception and not routine for all patients. Therefore, choice c, child-resistant containers are never recommended because these may interfere with many patients ability to comply with therapy, is incorrect. Choice a, any missed dose always and immediately should be replaced by taking two doses, is incorrect. The approach for missed doses cannot be generalized and depends on individual circumstances. In any case, the advice of a healthcare provider should be sought before an oral cytotoxic dose is repeated. Choice b, any patient with a dry mouth should crush all medications and mix with water or other liquid to facilitate swallowing, is incorrect because oral cytotoxic capsules generally are considered to be biohazardous. These drugs are not to be manipulated in such a way as to aerosolize the cytotoxic drug, generate particulate matter, or otherwise create untoward environment conditions.